NCC241804_FRO Submitted_20240612

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Johnston CountyAdvanced ManufacturingTrainingFacility
Project Name
2. Location of land-disturbing activity: County Johnston City or Township Four Oaks
Highway/Street Boyette Road Latitude 35.443063 Longitude-78.420386
3. Approximate date land-disturbing activity will commence: March 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.39 AC
6. Amount of fee enclosed: $ $ ,500.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac= $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Vic Medlin E-mail Address [e-mail]
Telephone [phone] cell# N/A Fax# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Four Oaks Development Corp. 919-963-3112 919-963-3113
Name Telephone Fax Number
PO Box 610 304 N Main Street
Current Mailing Address Current Street Address
Four Oaks, NC 27524 Four Oaks, NC 27524
City State Zip City State Zip
10, Deed Book No.5264 Page No,685-688 Provide a copy of the most current deed.
Part B. 5994 773-777
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Town of Four Oaks Development Corp. [e-mail]
Name E-mail Address
PO Box 610 304 N Main Street
Current Mailing Address Current Street Address
Four Oaks, NC 27524 Four Oaks, NC 27524
City State Zip City State Zip
Telephone [phone] Fax Number 919-963-3113

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Type (print na Title or Authority
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ignature Date
I, I icti- , Z__' G r`S , a Notary Public of the County of To1-\
State of North Carolina, hereby certify that Y . c Nke.—&\ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this o(tY day of &)DveJ 9er- , 2a '73
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